When Legal Nurse Consultants analyze medical records, we had better be able to compare and contrast subjective and objective documentation. In other words, we earn our keep by determining what constitutes a subjective complaint versus an objective finding.
Sounds simple right?
Not so fast! While these terms are used all through medical documentation, they can be confusing. Here are some of the reasons why:
- Non-medical people often mix the terms
- Medical records themselves can be confusing
- Attorneys and claims representatives often don’t understand the condition or clinical picture from a medical perspective
- Information that falls under each of the objective or subjective categories are often misunderstood, misquoted, or confused.
To make matters even worse, there are medical terms that actually can fall under BOTH categories.
A case in point
Here is an actual Physical Exam taken from one of our company’s case files:
Physical exam: Abrasion to left knee, right 5th finger, thumb and chin. Lips also noted to be swollen. Elevated BP. Swelling noted to right hand, limited ROM, decreased strength, tenderness to touch. Glasgow coma score 15/15. Neurovascular intact.
So, is the physical exam findings objective or subjective? First let’s review the definitions.
<spaSubjective = Information that is reported by the patient, BUT cannot be verified or perceived by the examiner. The examiner should document SUBJECTIVE COMPLAINTS. The term subjective findings (or subjective symptoms) is wrong. Examples – feeling hot, pain, numbness, tingling or nausea.
Objective = Measureable abnormality or finding that is perceived by the examiner. The examiner would document OBJECTIVE FINDINGS. More obvious objective findings would be lab or diagnostic testing.
Here’s a map of the same Physical Exam that deciphers the objective and subjective elements:
Abrasion (objective)to left knee, right 5th finger, thumb and chin. Lips also noted to be swollen (objective) and painful (subjective).Elevated BP (objective.Swelling (objective) noted to right hand, limited ROM (likely both),decreased strength (likely both),tenderness to touch (subjective).Glasgow coma score 15/15 (objective) Neurovascular intact (objective).
Depending on what side of the case they’re on, attorneys and adjusters can end to focus on what seems to help their case. But a good evaluation depends on clear understanding and accurate interpretation of the objective AND subjective data. The entire clinical picture – along with associated diagnostics, radiological studies and lab tests all – should be considered.
This is where it can get tricky
You have to really understand your clinical information…all of it. It is at this point that legal nurse consultants often get called to help out on a file.
While a medical record may have all kinds of subjective complaints, the absence of objective data that could account for the complaints should raise a red flag – irrespective of what side of the case you are on.
Much of what LNCs do is analyze all the medical data fairly and report on it. People like me take that data and explain it clearly and concisely. This explanation often becomes a story that tells the reader what happened.
Harnessing technical know-how
So, here are a few tips to help you deal with the subjective versus objective issue:
- Look closely at all the data with a balanced view.
- Compare and contrast the information. Are there lots of subjective complaints with few objective findings? How does this honestly affect your case?
- Do any of the findings change or shift in any way through the medical record?
- Has the subjective complaints been thoroughly evaluated by clinical and diagnostic studies?
- Follow the course of subjective AND objective data through an accurate timeline.
- Be objective about the case or file, not subjective.
Finally, take the time to learn what is really subjective versus a measurable and verifiable finding. Even if you fully do not understand the clinical picture, a common sense approach to reviewing the data is always helpful.
Kari Williamson, BS, RN, LNCC, CCM BSN, is the founder and president of MKC Medical Management. Contact Kari at 865-551-6800 and firstname.lastname@example.org.